SHE IS 2 YEARS OLD. STANDING ABOUT 36 INCHES TALL, she has beautiful dark blue eyes rimmed with thick

black lashes. I have rarely seen lashes so dark and thick on a child this young. Topping it all off is a head of black

ringlets that fall in wonderful disarray. Her beauty is the kind a toddler accepts as her due, without attitude, pride, or selfconsciousness.

I have known her since she was a blip in her mother’s belly for 9 months before she fell into my hands

at her birth.

    Still, she is susceptible to flattery and knows that I think her ears are absolutely the most beautiful ears I have ever

seen. I have told her so countless times. When I ask to look in them with my light, so I can see them really well, she cocks

her head just right formyexamination and is only too pleased to share these special ears with the woman who has been

    Ear infection diagnosed, Michelle Marie moves on to her own most important agenda. She whispers in her mother’s

ear and is told to go ahead and ask Dr Stacey her question. So she turns to me and lisp-whispers a soft request. Mom

translates: “Can I have a lemon off the tree?” At this time of year the lemon tree outside our office front door is loaded

with ripe lemons and Michelle Marie wants one of those bright yellow prizes. I explain to her that the tree actually

belongs to my landlady, but I am certain no one will mind if she picks one perfect lemon and takes it home. At this

news she runs out to the front door as fast as her toddler legs can carry her.

    I stand and watch this little family leave my office. Michelle Marie spends a few moments choosing her lemon and, under

the watchful eyes of her mother and baby brother, she picks it off the tree. The three of them load up in their van,

all seemingly satisfied with this latest visit to their family doctor.

    My heart swells with many emotions. I am going to miss Michelle Marie moments. I have lived

on moments like this for several years now, taking only enough actual cash home from my small family practice to

cover the mortgage and the taxes. I have told myself that it is worth it, that I don’t need a lot of money, that I can be

content to care for those I love even if I have to scramble for my quarterly malpractice premiums. Watching Michelle

Marie grow up, providing a safe and friendly place for her when she is sick and hurting, and being a part of her family

when they need me have all been compensation for the many long hours I have worked.

    This is changing. My self-worth, my self-respect, and my own life happiness are finally going to be a priority. After a

lifetime of dutiful decisions that have taken others into account before my needs, I will now live a life of my own. Will

I regret saying good-bye to Michelle Marie? I can’t imagine letting that go, and maybe I won’t have to.

    Allow me to explore a different reality for a few moments. In this alternate reality, physicians are reimbursed

for their services appropriately. The time put into education and training is respected, the time spent caring for patients

at all hours, on the telephone, and on the Internet in addition to regularly scheduled office appointments is reimbursed

appropriately. Physicians are still respected for their good will and earnest efforts. They are so content with their

choice of profession that they earn that respect. The physicians are courageous; they have time to listen to their patients

and are allowed to practice the art of medicine free from the restrictions created by contracts between health

plans and pharmaceutical companies. Services provided are not discounted, and each encounter does not come with a

mandatory write-off that sends a message to patient and physician both: “The service provided really wasn’t worth what

you think it should be.” Patients are aware of their responsibilities for their health and the limitations of modern medicine

and have realistic expectations of the health care system.

    The medical profession is attractive to intelligent and caring young students who know they can have a healthy

lifestyle and make a good living by being good physicians. Basic health care and preventive medicine are available to

everyone and not dependent on having a job with an employer who can afford to provide adequate and affordable

coverage. Self-employed persons and those with preexisting conditions have the same access to basic health care

as those who work for large companies. Dollars spent on health care go to the ones providing the care instead of the

bureaucratic administrators running the insurance industry.

    Lawmakers are not insulated by lifetime benefits and have the same health care needs as the “working class.”

A different reality, but one I believe most people would embrace. I also believe in working toward solutions, but I

do not yet see the path that leads us to a kinder, gentler, more effective health care system. The relationship I have

with Michelle Marie is precious and more valid than all the trappings of her health plan. But if insurance restrictions

and the industry of medicine can devastate our whole health care system, I imagine it can destroy the relationship a family

doctor has with her 2-year-old patient.

    So I watch Michelle Marie and her family climb into their van and I feel sadness and grief, for a system that is too sick

to allow medicine to be what we all say we want it to be: compassionate, loving, intuitive, and with time to pick lemons

off a tree, time to know each other well enough to care. And what will I do when all the patients have left and my

office is closed for the last time? I can work by the hour to make my expenses and not have to carry the weight of a business,

a call schedule, or a practice. I will take time to enjoy my own family without fear of being called away in the middle

of the night, to grow my garden, to gather my strength for the next endeavor.

    I am a doctor. I will always be a doctor. I am the kind of doctor who starts with respecting each unique human

being, who combines that special person with my best medical expertise, and then attempts to create a place for

healing. If I can find a way to work with my patients outside the cynical and restrictive attitude of the current failing

system, I will do so with joy. “Each of us has a fire in our hearts for something. It’s our goal in life to find it and

keep it lit.”* I will stoke that fire and keep it lit. I have not given up.

*Mary Lou Retton

A Piece of My Mind Section Editor: Roxanne K. Young, Associate Editor.

©2004 American Medical Association. All rights reserved. (Reprinted) JAMA, April 21, 2004—Vol 291, No. 15